The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR THE INSURANCE OF NEON SIGNS AND/OR HOARDINGS

Name of Proposer (in full)
Address :

Occupation or Business Paid Up Capital (if applicable) :

1 Particulars of the Hoarding or Neon Signs
(a) Full description along with
measurements of its size
(b) Year of manufacture
(c) By whom manufactured
(d) Price paid by proposer

2 Particulars of the Foundation and/or supporting structure on which Sign and/or Hoarding is errected.
The measurements of and the materials from which such foundation and/or supporting structure is constructed should be given
3. Has the structure of the sign been approved and passed by the Municipal or other Government Authority concerned ?

Does it require such approval ?
4. Will the Sign its foundation, supporting structure, fastening attachments etc. be regularly inspected by a duly qualified Electrician and Engineer if so, by whom and at what intervals.
5. Will the repairs or defects found by these inspections be immediately carried out or set rights
6. What are the measures adopted for the prevention of loss or damage occurring as a result of the falling down of the Sign.
7. Particulars of the property on which the sign is erected and / or attached to

(a) Is the sign affixed to the wall or
erected on the roof of a building
(b) State the address and the situation of
the building
(c) What is the approximate age of the
building
(d) Is the building in a sound condition
(e) Is the building a butting on to a main
thoroughfare.
(f) How far away is the nearest building
or structure from the building on
which the Sign is installed.
(g) How for away is the building
concerned situated from the Road or
Street or Kerb on all sides.
(h) Give brief information and
particulars of the surrounding area of
the building.
(i) If the Sign/Hoarding is erected or
placed on the roof of a building,
please state whether the roof is flat or
gabled and how far in is it from the
edge of the roof on all sides.
(j) If the sign is erected on the ground
give full particulars of its
surroundings.
How far away is it from any public or
other pathways, thorough fares,
streets, roads, etc..
(k) How high is the Sign/Hoarding from
ground level.
(l) How high is the sign/Hoarding from
roof level.
8. Have any claims been made against you in the last five years in respect of accidents caused directly or indirectly by the Sign/Hoarding. If so, give full particulars.
9. Has any Company:
(a) declined your proposal?
(b) refused to renew your policy?
(c) demanded an increased rate on
renewal?
(d) cancelled any of your insurances?
10 Have you received any notice from any person or authority regarding any defect in the Sign/Hoarding ?
11. Amount of Indemnity required:
(a) In respect of loss of or damage to the
Sign/Hoarding?
(b) In respect of Third Party Liability:
(a) Any one Accident:
(i) Personal Injury
(ii) Damage to Property
(c) For all Accidents in any one period
of Insurance

I/WE HEREBY DECLARE AND WARRANT that the above statements are true and complete. I/We desire to effect an Insurance with The Company, and I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the Company and I/We agree to accept a Policy subject to the conditions prescribed by the Company.

Proposer’s Signature______________________________

Date ____________________

Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Insurance is the subject matter of solicitation.

PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.

FOR OFFICE USE -
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal.

Name and Code No. Signature of Dev. Officer / A/AO-D

ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-
COLLECTION / SCROLL NO POLICY NO.
.